Medical Ethics case study

Sandra, an exceptionally bright and articulate 13 year old, is found to have a cancerous tumour in one eye. The tumour is growing rapidly. Surgery is required and the surgeons believe it likely that a blood transfusion will be required during the operation. Sandra’s parents make it clear to you that they are unwilling to give their consent to any procedure which involves giving her blood products. Initially, Sandra agrees with them, even though you explain to her the risks involved. However, later on, when you and your colleagues are alone with Sandra, she tells you that she’s really very scared of dying and would like you to do whatever you think is best. What should you do, and what ethical considerations should inform your decision ?  

Most interesting ethical questions involve conflict between the demands of two (or more) commonly-held moral values.  In this case, the conflict is between the duty of the medical team to preserve life and promote recovery, the duty to respect the instructions of the parents, who have explicitly refused to consent to the use of blood products, and (perhaps) a duty to Sandra to pay attention to her wishes. If the parents did consent, or if Sandra's well-being would not be affected by withholding blood products, then there would not be a dilemma.

One response to this problem is just to follow whatever guidelines are laid down by the relevant authorities. Although there are legal guidelines and procedures for this kind of situation (and medical law is an integral part of our course), the mere fact of their existence isn’t enough to show that they are the right guidelines and procedures. And this is the ethical question that we really want an answer to: what are the right guidelines for situations such as this? The fact that they are legal guidelines might be an argument for following them - most people think that we have a duty to obey the law- and we might think that it is better for everyone to follow the ethical guidelines than for individuals to ignore them at will.  But this will not settle the argument about what ought to be done, about what the guidelines ought to be.

One apparently attractive option in this case is to argue that Sandra - although only 13 - is very articulate, very bright, and has a maturity beyond her years that would allow healthcare professionals to consider her consent to be more important than that of her parents – it’s her life, after all.  This would enable the medical team to use blood products if they are needed to save her life, and this seems to present a neat way out of the problem. The duty to save life is met, the duty to obtain and follow consent is met.  The parents were overruled, but they can have no real complaint since Sandra is obviously able to make her own decisions.

However….

What if the situation was slightly different? What if it was Sandra who thought that using blood products was morally wrong, and her parents who were so scared of losing their daughter that they were prepared to consent to the use of blood products, even though she objected? If Sandra's consent is allowed to overrule her parent's view in the first case because she is very bright and very mature, surely we ought also to be prepared to let her refusal to override her parents’ consent in the second case, otherwise we could be accused of being inconsistent.

One possible response to this objection would be to say that being prepared to risk death rather than receive blood products would be a sign that Sandra was not mature enough to make such a decision, as she obviously doesn't really understand death. But if we say that, we’ll have to say in the first case that her parents don’t really understand death either. A response like this could be criticised for being paternalist, or dismissive, or intolerant of other cultures and belief systems; and that doesn’t seem ethically satisfactory at all.

There is no ready, simple answer to this very difficult dilemma.  Working out what to do in a case like this can take all the moral thoughtfulness and sensitivity and reasonableness that we can muster.  We can increase our sensitivity, sharpen our moral reasoning skills, by thinking hard about such cases, and the moral theories which underlie our responses to them, in a context of academic inquiry and discussion.  This is what our MA course aims to provide.

Welcome to Ethics at Keele!